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Rose is a 14-month-old indigenous Australian girl who presented initially at age 5 months with an immobile right arm and elbow swelling. She was afebrile, and otherwise clinically well with moderately elevated inflammatory markers (erythrocyte sedimentation rate (ESR) 35, C reactive protein (CRP) 42). Her initial imaging demonstrated inflammatory changes along the lower portion of the shaft of humerus, which on subsequent imaging was noted to have centred more around the elbow joint (figure 1). She was diagnosed with osteomyelitis/septic arthritis of the distal right humerus and elbow joint, and started on flucloxacillin, but the swelling failed to settle and she underwent a surgical washout which demonstrated a purulent exudate within the adjacent elbow joint. No bacterial, fungal or mycobacterial cause was isolated, from either blood or tissue, and she was eventually treated empirically with a variety of antibiotics for resistant organisms. Rose's illness then followed a protracted course with fluctuating elbow swelling and inflammatory markers which seemed to rise and fall independently of treatment. She was investigated for immune deficiency, however in the absence of any microbiological diagnosis this was seen as highly unlikely and was uninformative. Finally, after several months and 14 washouts the patient had clinically settled while on clindamycin and was discharged home on oral therapy, but with questions remaining as to whether this intervention had played any role in her improvement.

Comment

▶ Acute infective osteomyelitis and septic arthritis are uncommon diagnoses in children with an annual incidence of 1/5000 to 1/10 000.12Staphylococcus aureus is the predominant causative organism (>80% of cases)2 with approximately 10% of such cases being methicillin-resistant worldwide, although prevalence depends on local epidemiology.34 Less commonly a number of other organisms …

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